You Can't Always Get (or Give) What You Want: Preferences and Their Limits

People who lack decision-making capacity may be able to communicate preferences, which can and should inform surrogate decision-making on their behalf. It is unclear whether making a further distinction about "capacity for preferences," as Jason Wasserman and Mark Navin propose in this issue of the Hastings Center Report , would improve the process of surrogate decision-making. Anyone who is regularly involved in surrogate decision-making or who has worked to articulate decision-making standards and processes can think of cases in which a patient's voice was ignored or his or her preferences and ability to communicate them overlooked. However, we can also think of cases in which it was unclear whether information provided by a patient, recently or in the past, should have been characterized as a preference relevant to a medical decision that the patient lacked the capacity to make. We should also recognize that clear preferences of a patient who lacks decision-making capacity may conflict with the limits of another person or of a family's resources such that these preferences cannot guide a surrogate's decision. This patient will not get what he wants. A situation in which preferences are known and make sense but cannot be applied in a feasible way demonstrates the limits of the medical decision-making framework concerning care that is not covered by medical insurance.